Cartilage Tympanoplasty

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Cartilage Tympanoplasty
K. Kevin Ho, MD Tomoko Makishima, MD PhD Univ. of
Texas Medical Branch, Dept. of Otolaryngology
Grand Rounds Presentation March 19, 2008
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History of Tympanoplasty

• Banzer (1640) repair TM w/ pigs bladder.
• Toynbee (1853) rubber disk.
• Blake (1877) paper patch.
• Zoellner and Wullstein in 1952, using STSG
• 1958 Jansen
• First reported use of cartilage in OCR
• 1963 Salen and Jansen
• First reported use of cartilage for
  reconstruction of the TM

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Tympanic Membrane

• Oval shape.
• 8x10 mm.
• 55 angle w/ respect to floor of meatus.
• 130 µm thick.
• 3 layers
• Outer epithelial keratinizing squamous
• Middle fibrous superficial radial, deep
  circular
• Inner mucosa

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Tympanic Membrane Perforations

• Etiology
• Middle ear infections.
• EAC infections.
• Blunt Trauma.
• Iatrogenic.

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Risk factors for Re-perforation

• Large perforation (Lee P 2002)
• 56 success vs. 74 in small perf
• Anterior location (Bhat NA 2000)
• 67 success vs. 90 in posterior perf
• Disease in contralateral ear (Ophir D 1987)
• Otorrhea during surgery (Lau T 1986)
• Middle ear mucosa status (Albu S 1998)
• Smoking (Becvaroski Z 2001)

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Age and Success of Cartilage Tympanoplasty
Albera et al, 2006 EBM III
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Graft Materials

• Fascia
• Perichondrium
• Vein
• Dura
• Skin
• Cartilage

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Why Cartilage?

• Fascia and perichondrium undergo atrophy
• Skin graft Infection
• Cartilage
• More rigid and resist resorption
• Good long-term survival
• Nourished largely by diffusion

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Mucosal Traction Theory

• Mucosal layers of TM and middle ear linings
  undergo constant migration
• ETD creates the initial retraction and contact
  between mucosa of TM and ossicles
• If mucosa of TM and ossicles are coupled by
  mucous or fibrous adhesions, migratory forces
  pull mucosa towards the incus
• Mucosal traction plays a stronger role than
  Eustachian tube dysfunction in forming
  cholesteatoma

Jackler Otology Update 2006 EBM V
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Indications for Cartilage Tympanoplasty

• Atelectatic ear
• Retraction pocket/ Cholesteatoma
• High Risk Perforation
• Revision
• Anterior perforation
• gt 50
• Otorrhea at the time of surgery
• Bilateral

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Techniques

• Perichondrium/ Cartilage island flap
• Tragal cartilage
• Cartilage shield technique
• Conchal cartilage
• Palisade technique
• Tragal cartilage
• Concha cymba
• Inlay Butterfly graft
• Tragal cartilage

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Inlay Butterfly Graft

• Originally designed for small perforation
• (lt 1/3 TM diameter) myringoplasty without
  cholesteatoma
• Inlay technique without elevation of
  tympanomeatal flap
• Quick office procedure
• Expanded recently to repair larger perforations
  in conjunction with mastoidectomy
• Split thickness skin graft over perichondrium for
  large perforation

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Inlay Butterfly Graft
Eavey RD 1998
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Placement of Butterfly graft
Eavey RD 1998
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Postop Inlay Butterfly graft
Eavey RD 1998
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Inlay graft for large perforation
Ghanem MA 2006
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Tragal Cartilage Harvest

• Cut on medial side of tragus
• Leave 2 mm tragal cartilage for cosmesis
• Abundance 15 x 10 mm
• Flat
• 1 mm thickness
• Perichondrium from the side away from the EAC is
  removed

Dornhoffer 2003
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Perichondrium/ Cartilage Graft
Dornhoffer 2003
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Medial Grafting
Dornhoffer 2003
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Postop Perichondrium/ Cartilage Island Graft
Dornhoffer 2003
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Cartilage Shield
Aidonis I 2005
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Cartilage Shield
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Palisade technique

• This technique is favored when OCR is performed
  in malleus-present situation
• Cartilage from either tragus or cymba
• Post-auricular Cymba
• Transcanal Tragus

Dornhoffer 2003
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Conchal Cartilage Graft
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Palisade techniques
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Preparation of Cartilage Strips
Kazikdas KC 2007
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Palisade technique
Anderson J et al. Otol Neurotol. 2004
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Palisade Postop result
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Modified Palisade technique
Murbe D 2002
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Postop care

• 2 weeks postop Gelfoam completely suctioned from
  EAC
• Start topical antibiotics x 2 weeks
• Adult Start valsalva
• Children Otovent TID
• 3-4 months Audiogram
• Air bone gap
• Tympanogram no longer reliable. Type B tymp
  despite normal hearing

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Criticisms of Cartilage T-plasty

• Time consuming to shape cartilage
• Opaque - Difficulty in surveillance
• Rigidity of cartilage raises concern about
  audiologic outcome

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Effect of TM perforation on Hearing

• Diminished surface area on which sound pressure
  can exert
• Decreased area effect of TM stapes footplate
  (normally 171)
• ? dampening of lever action of the ossicular
  chain
• Sound reaching round window at same intensity and
  phase as oval window ? cancelling fluid
  vibration in cochlear
• Sound pressure entering the perforation acts on
  the medial surface of the TM against that on the
  lateral surface

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Hearing Results Dornhoffer et al.

• 95 patients who failed at least 1 temporalis
  fascia graft tympanoplasty
• 29 required OCR
• Avg f/u 12 months
• 90/95 (94.7) with successful TM closure
• Pediatric group has similar success rate as
  adults
• PTA (p lt 0.001)
• Preop 24.6
• Postop 12.2

EBM III
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Hearing Results Gerber 2000

• 11 patients
• 2 groups Cartilage vs. temporalis fascia
• Intact ossicular chain
• Size of graft 1/3 2/3 of mesotympanum
• Tragal cartilage island graft (10), conchal (1)
• Primary indication Retraction pocket
• Post-auricular or transcanal
• Average f/u 12 months

EBM III
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Hearing Results Gerber 2000
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Hearing Results Gerber 2000
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Thickness of Cartilage graft
Murbe D 2002
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Acoustic Properties
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Management of Middle ear effusion postop

• Appearance of TM
• Air-bone gap on audiogram
• CT temporal bone
• Initial treatment
• Nasal steroids
• Valsalva
• 3 months
• Surgical treatment
• Myringotomy (eg. CO2 laser)
• Tympanostomy tube (eg. soft Goode tube)

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Pediatric patients

• Avoid T-plasty lt 3 years
• Repair at age 4
• If contralateral ear is perforated, perform
  adenoidectomy and defer until age 7
• Cartilage tympanoplasty in the worst ear

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High Risk perforation

• Account for 1/3 cases of cartilage tympanoplasty
• gt 95 successful closure of TM after cartilage
  t-plasty
• 5 requires postop MT
• Hearing results comparable to fascia graft

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Ossicular Chain Reconstruction

• Cartilage reinforces prosthesis to prevent
  extrusion
• When malleus is present
• Palisade technique over island flap (obscure
  malleus and reconstruction)
• When malleus is absent
• Tragal cartilage island flap

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Cartilage T-plasty with TORP
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Cholesteatoma

• Palisade technique preferred
• Allow precise placement of prosthesis against the
  malleus
• Leave anterior TM without cartilage to allow
  surveillance and future tube placement
• Consider 2nd look if sac disrupted during initial
  cholesteatoma excision

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Pervasive Eustachian Tube Dysfunction

• Criteria for intraoperative tube placement
• Craniofacial abnormalities
• Nasopharyngeal carcinoma
• Recurrent otitis media with ETD
• Round knife used to create a window in the
  anterior graft
• Goode tube placed prior to insetting the graft

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Conclusions

• Cartilage tympanoplasty is a reliable technique
  in reconstruction of TM
• Hearing results after cartilage tympanoplasty is
  comparable to temporalis fascia graft
• Choice of techniques depend on surgeons
  preference, status of ossicular chain,
  Eutstachian tube, presence of cholesteatoma, etc.

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Thank You!